Behind The Scenes Of A Great Performance Improvement Plan in Healthcare

Based in Roanoke, Virginia, Carilion Clinic is a not-for-profit healthcare organization that includes hospitals, primary and specialty physician practices, and other complementary services that provide care to nearly 1 million people. The clinic’s mission is to “improve the health of the communities we serve,” and its vision is to “better patient care, better community health, and lower cost.”

Due to evolving legislation and an increasing number of patients, it’s critical to develop programs for performance improvement in healthcare organizations. Carilion Clinic sets a standard worth learning from. We recently sat down with Darren Eversole, Director of Finance, to learn more about the system Carilion Clinic put in place to track and improve performance across all of its facilities, departments, and providers. Keep reading to see what he had to say and get some ideas for your organization.

When did you start your healthcare performance improvement efforts?

Carilion’s first scorecards came into existence in 2007, so we’ve been working at this for about 13 years. And when I use the term “scorecard,” I’m referring to performance improvement opportunities that are part of overarching efforts to improve our overall quality, while lowering the cost of care to our patients.

Our process is based on the Balanced Scorecard methodology developed by Drs. David P. Norton and Robert S. Kaplan. Carilion Clinic’s former CEO had his leadership team read “The Balanced Scorecard” book, which we still use as the foundation of our approach and general performance improvement philosophy.

What were some of the first scorecards that appraised your healthcare performance?

Back in 2007, we started by developing a performance scorecard for senior leadership. A few years later, we created specific scorecards for our provider practices—both advanced care providers (ACP) and physicians—because we wanted to link compensation to patient-centered care. By creating specific scorecards that were unique to the providers—whether it was a department, section, or even individual—those providers were better rewarded for outcomes that were aligned with the mission of the clinic.

Both the leadership and provider scorecards gave us a way to accurately track hard metrics that tied to the mission and vision of Carilion Clinic, versus relying on subjective information.

How did these healthcare performance improvement opportunities develop over the years?

The scorecards have evolved quite a bit and it’s a continual best-practices effort for our organization. It’s currently a seven-month process to create the scorecards for the next year, so it’s something we dedicate a lot of time and effort to.

Over the years, the number of scorecards we use has expanded. There are three general categories:

• Clinic Scorecard: This is Carilion’s overall scorecard and it contains a handful of high-level metrics that span the entire organization. For example, one metric could be “time from scheduling to time from service for new patients.” This would tell us the number of days it takes a new patient to see the provider, from the time they schedule to the time they actually have the appointment. This metric specifically demonstrates “access to care” and looks at workflows, provider templates, and retaining/recruiting providers.
• Department Scorecard: Each department has its own scorecard with unique metrics that apply to the team of providers within the department. One metric that could apply to a department is “surgical site infection rate.” For a department with multiple subspecialties that perform frequent surgeries, infection rate is a common measure that could be used across the many teams.
• Section Scorecard: These scorecards tie to a specific team within a department, such as Internal Medicine or Dermatology. Patient experience metrics are usually found on section scorecards. For example, “physician kept you informed” (calculated based on patient survey responses) is a popular one and measures a common goal the team aims for together.
• Provider Scorecard: These scorecards contain measures that are tied to the results of an individual. Patient experience and managed care measures are typically included on provider scorecards.

Also, the information on our scorecards has changed. For example, one of our first clinic scorecards tracked about 70 measures. When you break that down, each measure had a negligible weight and consequently, didn’t tell us anything meaningful. Over the years, we reduced the measures for that scorecard from 70 to 20, and then to 13, 9, and currently to 7. Seven measures are much more meaningful and each aligns with the major categories of our Carilion Vision 2025 strategic plan.Having that refined list of only the most important measures and ensuring they link to your organization’s strategy was a big lesson learned for us.

What are some positive results you've achieved from implementing the healthcare performance improvement scorecards?

We publicize our scorecards and measures everywhere, presenting them to multiple audiences throughout the year—from physicians and management to senior leaders and board members. We also plan to post the clinic scorecard to our intranet, so all Carilion employees will have access to it soon. Once we began using ClearPoint, whose software is built to handle performance management in healthcare organizations, our scorecards became much more visible.

This increased visibility has made it easy to communicate what we’re tracking and how we’re performing. Not only does everyone know what’s expected of them and the metrics we need to hit to reach certain goals, but it leads to a greater understanding of why compensation (either for employees or physicians) may be affected for a particular year.

‍These performance improvement scorecards have also been effective tools for helping us identify where we have shortfalls or areas of opportunity. For example, we’re working on a three-year outlook for our clinic scorecard that states things like, “We want to be at X% in three years for measures A, B, C.” We may adjust the targets and limits on the scorecards, but we have a clear roadmap for where we want to be in the future.

What advice would you give to other healthcare organizations about performance improvement?

I would say that it’s very important to understand the needs of your organization and the stakeholders within it, and then be realistic about the extent of your internal capabilities. The larger the organization, the more scorecards you’ll develop, manage, and share. But don’t just add measures to add them, or create more scorecards because people are asking for them. Stay focused on what’s important based on your organization’s mission and needs.

After determining your needs and capabilities, find a good software product to help you manage your healthcare performance improvement program. Before working with ClearPoint, we used a system that had a lot of issues and it took significant tweaking just to create a scorecard. ClearPoint is much more user-friendly and efficient. Primarily, we use the software to:

• Easily generate and share performance reports with 1000 providers (on an automated schedule) and senior leadership
• Perform advanced calculations that roll up to different measures
• Use an API to automatically pull data from other internal applications into ClearPoint

Your software provider should not only offer a powerful system that saves you time, but also be responsive when you reach out with questions or feedback.

What’s next for Carilion Clinic’s performance improvement efforts?

How we use our scorecards is growing, or rather, becoming more robust. We’re realizing a need to add more scorecards since managers and directors see the value and are requesting them, but want to make sure we’re developing them thoughtfully—we only want to track the most important performance measures. I'm hoping that our program is growing at a healthy rate and these scorecards will continue being effective tools for our organization.